Resorbable Versus Titanium Hardware for Rigid Fixation of Pediatric Upper and Midfacial Fractures: Which Carries a Lower Risk Profile?

PURPOSE: Titanium associated risks have led to interest in resorbable hardware for open reduction and internal fixation (ORIF) of pediatric facial fractures. This study aims to systematically review and compare the outcomes of titanium/resorbable hardware used for ORIF of upper/midfacial fractures to determine which hardware carries a higher complication rate in the pediatric patient. METHODS: Studies published between 1990 and 2020 on the ORIF of pediatric upper/midfacial fractures were systematically reviewed. A retrospective institutional review was also conducted, and both arms were compiled for final analysis. The primary predictor value was the type of hardware used and the primary outcome was the presence of a complication. Fisher's exact test and 2-proportion 2-tailed z-test calculations were used to determine statistical significance, which was defined as a P value < .05. The low quality of published evidence precluded meta-analysis. RESULTS: Systematic review of 23 studies identified 659 patients, and 77 patients were identified in the institutional review. A total of 736 patients (299 resorbable, 437 titanium) were included in the final analysis. Total complication rate was 22.8%. The titanium group had a higher complication rate (27 vs 16.7%; P < .01), and more often underwent elective hardware removal (87.3 vs 0%, P < .01). In each hardware subgroup, the incidence of complications was analyzed by fracture site. In the titanium group, complication incidence was higher when treating maxillary fractures (32.8 vs 22.9%, P = .03). When comparing the 2 hardware groups by fracture site, maxillary fractures had a higher rate of complications when treated by titanium hardware compared with resorbable hardware (32.8 vs 18%, P < .01). CONCLUSIONS: Upper/midfacial pediatric fractures requiring ORIF, especially maxillary fractures, may be best treated with resorbable hardware. Additional hardware-specific outcomes data is encouraged.

Pneumomediastinum following hyperbaric oxygen therapy for carbon monoxide poisoning: case report.

A 5-year-old boy trapped in a house fire was transported to the emergency department, unconscious with suspected carbon monoxide poisoning. The patient underwent a difficult intubation, but did not initially demonstrate any radiographic abnormalities. The patient remained intubated and underwent hyperbaric oxygen therapy using the carbon monoxide treatment protocol. Immediate post-therapy chest radiograph revealed the development of occult pneumomediastinum. The patient remained stable on positive-pressure ventilation and the pneumomediastinum resolved spontaneously. The patient was extubated on post-injury Day #2 and was discharged post-injury Day #4 with no residual clinical sequelae. The development of pneumomediastinum associated with hyperbaric oxygen therapy for carbon monoxide poisoning appears to be a rare phenomenon. However, clinicians should be aware of the risk factors that predispose patients to developing pneumomediastinum and have a low threshold for obtaining routine pre- and post-procedure screening chest radiographs in intubated and critically ill patients, particularly in children.

Resorbable Versus Titanium Rigid Fixation for Pediatric Mandibular Fractures: A Systematic Review, Institutional Experience and Comparative Analysis.

Study Design: Pediatric mandible fractures mandate special consideration because of unerupted teeth, mixed dentition, facial growth and the inability to tolerate maxillomandibular fixation. No consensus exists as to whether resorbable or titanium plating systems are superior with regards to clinical outcomes. Objective: This study aims to systematically review and compare the outcomes of both material types in the treatment of pediatric mandible fractures. Methods: After PROSPERO registration, studies from 1990-2020 publishing on outcomes of ORIF of pediatric mandible fractures were systematically reviewed according to PRISMA guidelines. An additional retrospective review was conducted at a pediatric level 1 trauma center. Results: 1,144 patients met inclusion criteria (30.5% resorbable vs. 69.5% titanium). Total complication rate was 13%, and 10% required a second, unplanned operation. Complication rates in the titanium and resorbable groups were not significantly different (14% vs. 10%; P = 0.07), and titanium hardware was more frequently removed on an elective basis (P < 0.001). Condylar/sub-condylar fractures were more often treated with resorbable hardware (P = 0.01); whereas angle fractures were more often treated with titanium hardware (P < 0.001). Within both cohorts, fracture type did not increase the risk of complications, and comparison between groups by anatomic level did not demonstrate any significant difference in complications. Conclusions: Pediatric mandible fractures requiring ORIF are rare, and hardware-specific outcomes data is scarce. This study suggests that titanium and resorbable plating systems are equally safe, but titanium hardware often requires surgical removal. Surgical approach should be tailored by fracture anatomy, age-related concerns and surgeon preference.

Unfavorable outcomes with vertical reduction mammaplasty: part II.

BACKGROUND: Vertical reduction mammaplasty is a procedure that has steadily increased in popularity in the United States. Although numerous techniques exist for performing this operation, the adverse outcomes are similar in nature regardless of the approach. The authors previously evaluated patient satisfaction with vertical reduction mammaplasty in 260 consecutive patients in Part I. OBJECTIVE: This study evaluates the unfavorable outcomes encountered by the authors in the same patients included in Part I and examines the range of complications seen in other studies. METHODS: The authors reviewed the charts of 260 consecutive patients who underwent vertical reduction mammaplasty by the senior author at one of four institutions. All surgeries were performed through a superior pedicle vertical incision technique with varying amounts of liposuction. RESULTS: Unfavorable outcomes at our institution included scarring (10%), necrosis (1.92%), wound dehiscence (10%), areola asymmetry (6.54%), breast distortion or asymmetry (15%), and hematoma or seroma formation (1.54%). The results varied greatly in severity and necessity of intervention. CONCLUSIONS: While there is a wide spectrum of complication rates among the different techniques of vertical reduction, the outcomes are often similar. The authors have observed these complications in a broad patient demographic and believe that the examples provided in this article can be extrapolated to other vertical incision techniques. An assessment of these complications is necessary to provide patients with proper preoperative counseling about the risks and consequences of these potential sequelae. In our experience, more significant resection and suction produced less cosmetically favorable results.